Histopathological Findings in Hernia Sacs: A Clinical and Pathological Review.

Routine histopathological examination of hernia sac in adults remains a controversial topic. We undertook a retrospective study to assess possible clinical benefits of pathological examination of hernia sac specimens. Our pathology database between 1992 and 2020 was searched for adult specimens submitted as hernia sac. The clinical and pathological data of patients with abnormal histopathological findings were reviewed. There were 5424 hernia sac specimens (3722 inguinal, 1625 umbilical, and 77 femoral), 32/5424 (0.59%) with malignancies (28 epithelial and 4 lymphoid) and 25/32 were located in the umbilical region. Twelve out of twenty-five malignancies (48%) presented as primary clinical manifestations of the diseases (5 GI tract carcinomas, 5 gynecological tract carcinomas, and 2 lymphoid neoplasms); and 13/25 (52%) specimens were involved by previously known tumors (8 gynecological carcinomas, 3 colon carcinomas, 1 breast carcinoma, and 1 lymphoma). Among the 7 inguinal hernia sacs with malignancies, 3 (42.9%) were primary presentations of the tumors (2 prostatic carcinomas, 1 pancreatic carcinoma), and 4 (57.1%) were previously known tumors (2 ovarian carcinomas, 1 colon carcinoma, 1 lymphoid). Benign lesions were 12/5424 (0.22%), including 7 adrenal rests, 4 endometriosis, and 1 inguinal sarcoidosis. The incidence of hernia sacs with malignancies was 32/5424 (0.59%), most commonly from nearby organs in gynecological tract. However distant metastases from breast were also present. Near half of the hernia sac with malignancies (15/32, 47%) presented as the first clinical manifestation. Routine histopathological examination of hernia sac in adults is recommended, since it may provide important clinical information.

The Role of Hindu Mandirs in Addressing Intimate Partner Violence Among South Asian American Communities.

There is a growing body of literature that documents high rates of intimate partner violence within South Asian American communities, indicating a critical need for research that can respond directly to this issue. From a socioecological perspective, Hindu temples can influence members' behaviors at multiple levels of change and thus may be important sites of collaboration for the prevention of intimate partner violence. Through in-depth qualitative interviews with South Asian families, temple leaders, and community stakeholders, this study indicates that Hindu temples have tremendous capacity to significantly impact intimate partner violence within South Asian American communities.

Metastatic Neuroendocrine Tumors to Parotid Gland: Where Do They Come From?

Background. Metastasis to parotid gland occurs mostly from skin cancers of the head and neck region. Metastatic neuroendocrine tumors to the parotid gland are rare and not well studied so far. In this study, we undertook a retrospective review of secondary neuroendocrine tumors of the parotid diagnosed in our institution. The most common entities, primary tumor locations, their clinical presentations and histopathological features were analyzed. Methods. Cases of secondary neuroendocrine tumors to parotid diagnosed from August 1995 to Jan 2021 were retrieved from our institution's pathology databases, and their clinicopathological features were reviewed. Results. About 29% (120 of 420 cases) of parotid neoplasms were malignant, including 70 cases of parotid primary malignant tumors and 50 cases of metastases to parotid glands. Among metastatic tumors to the parotid glands, squamous cell carcinoma and melanoma of the head and neck region together accounted for about 78% of the cases. Only 11 of 50 metastatic tumors to the parotid were neuroendocrine carcinomas (22%). The most common primaries were poorly differentiated neuroendocrine carcinoma of lung (5 of 11 cases), including 4 cases of small cell carcinoma and one case of large cell neuroendocrine carcinoma. The second most common secondary tumor was Merkel cell carcinoma (4 of 11 cases, 36%) including one case of direct invasion from overlying skin. Medullary carcinoma of the thyroid comprised the rest of the metastases to the parotid (2 of 11 cases, 18%). Conclusion. Our results show that metastatic neuroendocrine carcinomas to the parotid gland account for about 22% of all metastatic tumors to the organ. Lung is the most common primary neuroendocrine carcinoma location. It is not uncommon for metastatic neuroendocrine carcinoma to present as the first sign of systemic clinical manifestation. Merkel cell carcinoma is the second most common entity that metastasizes to parotid, followed by medullary carcinoma of the thyroid.

Clinicopathologic Review of Metastatic Breast Cancer to the Gynecologic Tract.

Metastatic spread is the single most significant predictor of poor survival in breast cancer. Some of the most common metastatic sites are the bones, lungs, liver, brain, and peritoneal cavity. Clinically metastatic breast cancer to the gynecologic tract is usually asymptomatic and diagnosed as an incidental finding during a histologic examination of gynecologic specimens resected for other reasons. Cases of metastatic breast cancer to gynecologic organs diagnosed from August 1995 to January 2021 were retrieved from our institution's pathology databases, and their clinicopathologic features were reviewed. The most common site of metastasis was the ovary which was involved in about 79% (22 of 28 cases) of metastases to the gynecologic tract. Clinically, only 8 cases (36%) presented with ovarian mass detected in imaging studies and the rest of the cases were all incidental findings. Among ovarian metastasis, 59% of cases were invasive lobular carcinoma and 41% were invasive ductal carcinoma. In 5 cases, metastatic breast cancer was found in the endometrium, including 2 cases with endometrial metastasis only and 3 cases with multiple gynecologic organs involved. Metastatic breast cancer rarely involved the lower gynecologic tract, with only 7% vaginal metastasis and 4% found in the vulva. The absolute majority of metastatic breast cancer outside of the ovaries were lobular carcinoma (88%). Most of the metastatic breast carcinomas were positive for estrogen receptor on immunohistochemistry (27 of 28 cases, 96%). Her-2/neu immunostaining was positive in 4 cases only (14%). Metastatic breast cancer needs to be distinguished from gynecologic primary neoplasms and metastatic tumors from adjacent urinary and GI tracts. A careful review of the patient's history and adequate immunohistochemistry panel are helpful to render the diagnosis.

Fine-needle aspiration of intramammary lymph nodes: a clinical, radiographic, and cytologic review.

INTRODUCTION: Recognizing and sampling intramammary lymph nodes (IMLNs) is important in the clinical management of patients with breast carcinomas. We undertook a retrospective study to evaluate the clinical utility of fine-needle aspiration (FNA) in assessing IMLNs. MATERIALS AND METHODS: Our pathology database was searched for all IMLN FNA cytology cases from January 2005 to December 2021. The cytologic findings, radiographic features, and clinical data were reviewed. RESULTS: A total of 149 cases were identified. Eighteen of 149 (12%) patients had synchronous breast tumors, including 13 invasive ductal carcinomas (IDCs), 1 ductal carcinoma in situ (DCIS), and 4 fibroadenomas. Among patients with synchronous IDCs, FNA of IMLNs was positive for metastatic carcinoma in 4 of 13 (30.7%) cases. The 4 patients with positive IMLNs all received mastectomies. Fifteen of 149 (10.7%) patients had a prior history of breast tumors, including 9 IDCs, 4 DCISs, 1 lobular carcinoma in situ (LCIS), and 1 fibroadenoma. Two of 149 (1.3%) patients had a prior history of lymphoma. In the patients with prior history of IDC, DCIS, LCIS, lymphomas and fibroadenomas, IMLN FNAs were all negative for malignancy. Two of 149 cases (1.3%) showed granulomatous lymphadenitis. The remaining 112 cases had negative IMLN FNAs and no significant clinical or pathological findings. CONCLUSIONS: Our study showed that IMLNs are commonly associated with synchronous/metachronous breast tumors (33 of 149, 22.1%). The incidence of positive IMLN FNA in patients with synchronous invasive breast carcinoma was 30.7% (4 of 13). FNA of IMLNs in conjunction with clinical presentation and radiologic findings allows triage of patients for appropriate clinical management and avoids additional unnecessary surgical procedures.

Eliciting patients' healthcare goals and concerns: Do questions influence responses?

There is increasing interest in asking patients questions before their visits to elicit goals and concerns, which is part of the move to support the concept of coproducing care. The phrasing and delivery of such questions differs across settings and is likely to influence responses. This report describes a study that (i) used a three-level model to categorize the goals and concerns elicited by two different pre-visit questions, and (ii) describes associations between responses elicited and the phrasing and delivery of the two questions. The questions were administered to patients with rheumatic disease, and patients with inflammatory bowel disease (IBD). Paper-based responses from 150 patients with rheumatic disease and 338 patients with IBD were analyzed (163 paper, 175 electronic). The goals and concerns elicited were primarily disease or symptom-specific. The specific goal and concern examples featured in one pre-visit question were more commonly reported in responses to that question, compared to the question without examples. Questions completed electronically before the visit were associated with longer responses than those completed on paper in the waiting room. In conclusion, how and when patients' goals and concerns are elicited appears to have an impact on responses and warrants further investigation.

Cytological features of endolymphatic sac tumors: Case studies with review of literature.

Endolymphatic sac tumors are extremely rare, locally aggressive neoplasms that arise from the endolymphatic sac or duct, primarily in the intraosseous portion. These neoplasms show diverse histomorphological architectures and despite a bland cytologic appearance, can locally recur. Although the clinicopathological and radiological features of this entity are well characterized, the literature on cytological features is extremely sparse. Herein, we describe the cytological features of the endolymphatic sac tumors and discuss the relevant differential diagnoses.

Mechanisms of change in drinking following an alcohol-related injury: A qualitative examination of the sentinel event effect.

Background: Sentinel events are negative health-related events that trigger change in risky health behaviors. Despite its presumed major role in behavior change, the sentinel event effect has received little empirical attention. Through analysis of qualitative interviews, we explored how sentinel events trigger behavior change. Methods: Thematic analysis and concept mapping were used to develop a preliminary model of the sentinel event effect among a sample of 24 adult heavy drinking Mexican-origin men previously admitted to a hospital due to injury. The model was checked against cases that did versus did not report change in alcohol use following an alcohol-related negative event. Results: Findings suggest that sentinel events may arouse negative emotional reactions, encourage reflection on the negative consequences of drinking, and cause reevaluation of the severity and significance of drinking. These processes may increase motivation to change. Conclusions: Findings support the concept of the sentinel event as a natural intervention, and identifies potential social-cognitive and motivational mechanisms through which it influences change. Findings stand to inform research on mechanisms underlying brief intervention effects, and research that seeks to identify treatment targets.

Dilemma in Diagnosis of Pyogenic Meningitis in Cerebrospinal Fluid Contaminated with Blood: Does Leucocyte Esterase Test Help?

CONTEXT: Pyogenic meningitis is often a devastating condition which is diagnosed by analysis of cerebrospinal fluid (CSF) obtained by lumbar puncture (LP). CSF thus obtained can get contaminated with peripheral blood leucocytes during LP which renders it unusable for cytological analysis. Leucocyte esterase strips are available for identifying leucocyte esterase activity in urine and other body fluids which suggest inflammation. We conducted this experiment to see whether the leucocyte esterase strip can differentiate between neutrophils invited at the inflammatory site and circulating neutrophils in CSF. AIM: To compare the diagnostic ability of the leucocyte esterase test between pyogenic meningitis and CSF contaminated with circulating neutrophils. SETTING AND DESIGN: Prospective analytical study conducted in a tertiary care hospital. MATERIALS AND METHODS: The CSF samples of pyogenic meningitis patients were analyzed for leucocyte esterase activity. The other group was normal CSF which was deliberately contaminated with buffy coat preparation, and leukocyte esterase activity was determined. STATISTICAL ANALYSIS: Diagnostic ability of a test in terms of sensitivity and specificity. RESULTS: Overall sensitivity of the dipsticks in diagnosing pyogenic meningitis is 81% and specificity is 99%. When compared with experimentally contaminated CSF sample, a reading of 2+ on the strip had a sensitivity of 70% and specificity of 100% for pyogenic meningitis. CONCLUSION: Leucocyte esterase strip is specific for pyogenic meningitis (activated neutrophils), and hence can differentiate from CSF contaminated with blood.

Ectopic Thyroid Tissue: Immunohistochemistry and Molecular Analysis.

Ectopic thyroid tissue is rare and controversial. Some experts consider it to always be metastatic thyroid carcinoma, whereas others consider it benign as long as it is restricted to few follicles without cytoarchitectural features of papillary thyroid carcinoma. Immunohistochemistry (IHC) and molecular studies have not yet been performed to further characterize this entity. We retrospectively searched our pathology files for all ectopic thyroid inclusions and reviewed clinicopathologic characteristics and concurrent thyroid pathologic findings. We identified 8 cases from 7 patients. Ectopic thyroid tissue was present in the following locations: neck soft tissue: 3, thymus: 2, neck lymph nodes: 2, perihilar soft tissue: 1. All patients had histologically benign thyroid specimens. BRAFV600E (VE1) IHC, HBME-1 IHC, galectin-3 IHC, BRAFV600E allele-specific polymerase chain reaction (PCR) and NRAS/KRAS pyrosequencing were performed. To assess the sensitivity and specificity of BRAFV600E IHC compared with PCR; we tested 13 cases of primary and metastatic papillary and follicular thyroid carcinomas. All the ectopic cases were HBME-1, galectin-3, BRAFV600E (IHC, PCR), and NRAS/KRAS mutation negative (specificity=100%). Compared with PCR, BRAF IHC had 89% sensitivity and 100% specificity. Lack of common carcinoma-associated mutations supports benign nature of this entity. BRAF, HBME-1, and galectin-3 IHC are accurate and helpful when not enough tissue is available for molecular studies. IHC and molecular studies are more helpful than morphology alone in identifying benign thyroid rests.

Sarcoidosis Following Anti-PD-1 and Anti-CTLA-4 Therapy for Metastatic Melanoma.

Immune checkpoint inhibitors represent the newest treatment for stage IV melanoma. These agents are generally well tolerated, however severe immune-related adverse effects have been noted in a small, but clinically significant percentage of patients. Specifically, sarcoidosis is a known potential complication following anti-CTLA-4 therapy. We present 2 cases of pulmonary and cutaneous sarcoidosis developing in patients with stage IV melanoma. Both patients were treated with ipilimumab and anti-PD-1 therapy, and both experienced good oncologic responses to treatment; neither had evidence of preexisting sarcoidosis. Of note, both patients developed sarcoidosis only after undergoing immune checkpoint inhibitor therapy. In 1 patient, sarcoidosis developed after initiation of anti-PD-1 therapy, 3 months after the last dose of anti-CTLA-4 monotherapy, suggesting a synergistic immune dysmodulating effect of both checkpoint inhibitors. Ultimately, both patients' symptoms and radiologic findings resolved with corticosteroid treatment, and both patients have tolerated retreatment with PD-1 inhibitors. Sarcoidosis is a rare complication of immune checkpoint inhibitors and can manifest with severe pulmonary manifestations. However, sarcoidosis in this setting is responsive to corticosteroids and does not necessarily recur with retreatment. It is yet unclear whether the development of sarcoidosis in these patients represents unmasking of preexisting autoimmune tendencies or is a marker of oncologic response.

A highly sensitive and specific combined clinical and sonographic score to diagnose appendicitis.

BACKGROUND: Computed tomography (CT) scanning reduces the negative appendectomy rate however it exposes the patient to ionizing radiation. Ultrasound (US) does not carry this risk but may be nondiagnostic. We hypothesized that a clinical-US scoring system would improve diagnostic accuracy. METHODS: We conducted a retrospective review of all patients (age, >15 years) who presented through the emergency department with suspected appendicitis and underwent initial US. A US score was developed using odds ratios for appendicitis given appendiceal diameter, compressibility, hyperemia, free fluid, and focal or diffuse tenderness. The US score was then combined with the Alvarado score. Final diagnosis of appendicitis was assigned by pathology reports. RESULTS: Three hundred patients who underwent US as initial imaging were identified. Thirty-two patients with evident nonappendiceal pathology on US were excluded. In 114 (38%), the appendix was not visualized and partially visualized in 36 (12%). Fifty-seven (21.3%) had an appendectomy with 1 (1.7%) negative. Six nonvisualized appendicies underwent appendectomy, with no negative cases. Sensitivity and specificity for the sonographic score were 86% and 90%, respectively, at a score of 1.5. The combined score demonstrated 98% sensitivity and 82% specificity at 6.5, and 95% sensitivity, and 87% specificity at a score of 7.5. Sensitivity and specificity were confirmed by bootstrap resampling for validation. Area under receiver operating characteristic (ROC) curves for our new US score were similar to the ROC curve for the Alvarado score (91.9 and 91.1, p = 0.8). The combined US and Alvarado score yielded an area under the ROC curve of 97.1, significantly better than either score alone (p = 0.017 and p < 0.001, respectively). CONCLUSION: Our scoring system based entirely on US findings was highly sensitive and specific for appendicitis, and it significantly improved when combined with the Alvarado score. After prospective evaluation, the combined US-Alvarado score might replace the need for computed tomography imaging in a majority of patients. LEVEL OF EVIDENCE: Diagnostic Test, Level III.

Utility of intraoperative frozen sections in surgical decision making for acute invasive fungal rhinosinusitis.

BACKGROUND: Acute invasive fungal rhinosinusitis (AIFRS) represents a fulminant, potentially fatal, disease process in immunocompromised patients. The diagnosis often rests on high index of clinical suspicion, with relative paucity of data on the diagnostic and therapeutic implications of intraoperative frozen sections. METHODS: Retrospective review was performed for 18 cases undergoing endoscopic sinus surgery for AIFRS. Reliability of intraoperative frozen section diagnosis was evaluated for all patients using final pathology as the gold standard. RESULTS: A total of 66 frozen sections were performed. Diagnostic accuracy of frozen sections illustrated sensitivity of 72.7% (95% confidence interval [CI], 0.57 to 0.85), specificity of 100% (95% CI, 0.85 to 1.00), positive predictive value (PPV) of 100% (95% CI, 0.89 to 1.00), and negative predictive value (NPV) of 64.7% (95% CI, 0.46 to 0.80). There was no statistically significant difference in sensitivity of frozen sections in cases of Mucor and Aspergillus at 68.8%% and 76.2%, respectively (p = 0.61). CONCLUSION: This study represents the largest series assessing the diagnostic accuracy of frozen section analysis in AIFRS. Frozen section analysis is an effective tool for guiding intraoperative decision making in patients with AIFRS with a high PPV. A Low NPV underscores the importance of clinical suspicion and intraoperative decision making based on endoscopic findings when negative frozen section results are encountered. Further, frozen section analysis appears to be equally effective in detecting either Mucor or Aspergillus.

Neutrophilic Fixed Drug Eruption.

Fixed drug eruption (FDE) is a cutaneous reaction to a medication that recurs in the same fairly localized site with each exposure to the offending drug. The classical histopathologic findings in FDE consist of an interface dermatitis with predominantly lymphocytic inflammatory cell infiltrate. An unusual case of FDE in a 27-year-old pregnant woman who presented with widespread lesions and a predominantly neutrophilic infiltrate on histopathologic examination is reported.

Imaging of the optic disk in caring for patients with glaucoma: ophthalmoscopy and photography remain the gold standard.

Optic disk imaging is integral to the diagnosis and treatment of patients with glaucoma. We discuss the various forms of imaging the optic nerve, including ophthalmoscopy, photography, and newer imaging modalities, including optical coherence tomography (OCT), confocal scanning laser ophthalmoscopy (HRT), and scanning laser polarimetry (GDx), specifically highlighting their benefits and disadvantages. We argue that ophthalmoscopy and photography remain the gold standard of imaging due to portability, ease of interpretation, and the presence of a large database of images for comparison.

Nanomaterials in the field of design ergonomics: present status.

Application of nanotechnology and nanomaterials is not new in the field of design, but a recent trend of extensive use of nanomaterials in product and/or workplace design is drawing attention of design researchers all over the world. In the present paper, an attempt has been made to describe the diverse use of nanomaterials in product and workplace design with special emphasis on ergonomics (occupational health and safety; thermo-regulation and work efficiency, cognitive interface design; maintenance of workplace, etc.) to popularise the new discipline 'nanoergonomics' among designers, design users and design researchers. Nanoergonomics for sustainable product and workplace design by minimising occupational health risks has been felt by the authors to be an emerging research area in coming years. PRACTITIONER SUMMARY: Use of nanomaterials in the field of design ergonomics is less explored till date. In the present review, an attempt has been made to extend general awareness among ergonomists/designers about applications of nanomaterials/nanotechnology in the field of design ergonomics and about health implications of nanomaterials during their use.

Emotion and interior space design: an ergonomic perspective.

Interaction between the users and their environment is spontaneous and unavoidable. This interaction can be positive or negative. A good interior space is about considering all the physical, environmental and cognitive elements and harmonizing them to make it a space that feels right, functionally and emotionally. The important element that has to be considered the most in an interior space is the "user". Balancing all these elements is a challenging job and results in a perfect interior space design. This paper intends to bring to light the necessity of designing an optimum interior space, which is a balance of the user's choice and the mandatory standards that ought to be followed for user safety and convenience. There has to be an intervening domain of ergonomics which will guide to bring out a balance between the personal choice of the user and the usual standards followed. It should also provide a step-by-step information, guidance and direction to act to the specifications and standards systematically to adapt an integrated approach of handling all the elements holistically which will indeed result in a good interior space.

HRT III glaucoma probability score and Moorfields regression across the glaucoma spectrum.

OBJECTIVE: To compare the agreement, sensitivity, and specificity of the Heidelberg Retina Tomograph III Glaucoma Probability Score (GPS) and Moorfields Regression Analysis (MRA) across the spectrum of glaucomatous visual field (VF) loss. DESIGN: Retrospective observational study. METHODS: Data from 247 glaucoma patients and 142 controls who underwent standard achromatic perimetry (SITA-SAP) and Heidelberg Retina Tomograph III imaging within 6 months were analyzed. Sensitivity, specificity, agreement, and discrimination capability of MRA and GPS were assessed. RESULTS: Age-adjusted specificity was 92% and 93% and sensitivity was 76.88 and 80.85 for GPS and MRA, respectively. Sensitivity for early VF loss [mean deviation (MD) < -5 dB] (N=81) was 66.64% and 69.82%, for moderate VF loss (-5 dB -15 dB) (N=62) was 87.70% and 86.48% (GPS and MRA, respectively). Age-specific receiver operating characteristics ranged from 0.89 to 0.92 and from 0.87 to 0.90 (GPS and MRA, respectively). Kappa ranged from 0.64 to 0.77. CONCLUSIONS: Specificity for MRA and GPS was similar and agreement was good. GPS offered slightly higher age-specific receiver operating characteristic. GPS, which does not require contour line placement, may have a potential role in screening for severe glaucomatous damage.

Ultrasound biomicroscopy of zonular anatomy in clinically unilateral exfoliation syndrome.

PURPOSE: To evaluate the ability of ultrasound biomicroscopy (UBM) to detect abnormalities in the zonular apparatus in unaffected eyes of patients with clinically unilateral exfoliation syndrome (XFS) using a standardized grading system. METHODS: The affected and unaffected eyes of 17 patients with clinically unilateral XFS and 17 eyes of 17 control subjects underwent UBM. Radial sections detailing the lens and zonules at 12:00, 1:30, 3:00, 4:30, 6:00, 7:30, 9:00 and 10:30 clock hours were obtained. The images were graded by a masked, experienced UBM observer using a standardized scoring system based on the zonular appearance (0, none; 1 and 2, uneven or disrupted zonules with or without patchy deposits; 3, diffuse granulation, thick zonules or both; 4, total zonular disruption). Affected meridians were compared by the Friedman test, while distributions of unaffected and affected eyes were compared using the Student t-test. RESULTS: In the control group, 15/17 eyes showed normal zonules; the remaining two eyes showed grade 1 changes in some meridians. The mean grade score was 0.33 [standard deviation (SD) 0.84]. Eyes with XFS had a higher score than control eyes, with a mean score of 14.35 (SD 7.14, P < 0.001, Student t-test). In clinically unaffected fellow eyes, the mean score was 10.53 (SD 7.44), and was less than that of XFS eyes (P = 0.008, Student t-test). Twelve XFS eyes (71%) and six unaffected fellow eyes (35%) had grade 3 or 4 in at least one meridian (P = 0.07, Friedman test). CONCLUSION: Bilateral zonular involvement is present in subjects with clinically unilateral XFS. These zonular changes may be extensive in fellow eyes without clinically evident exfoliation material. UBM assessment of zonular status in fellow eyes prior to cataract extraction may aid in surgical planning.